sole issue in this case is whether advanced registered nurse
practitioners (ARNPs) are per se disqualified from testifying
on proximate cause in a medical negligence case. For the
reasons discussed below, we hold that ARNPs may be qualified
to testify regarding causation in a medical malpractice case
if the trial court determines that the ARNP meets the
threshold requirements of ER 702. The ability to
independently diagnose and prescribe treatment for a
particular malady is strong evidence that the expert might be
qualified to discuss the cause of that same malady. We
therefore reverse the trial court and remand for further
proceedings consistent with this opinion.
and Procedural History
Frausto, a 70-year-old quadriplegic man, checked in to Yakima
HMA LLC for pneumonia. While there, the nurses allegedly
failed to provide proper care in the form of moving him,
turning him, and providing him with an appropriate bed. As a
result, Frausto developed pressure ulcers and filed suit
against the medical center.
HMA moved for summary judgment, arguing that Frausto had
failed to provide expert testimony as required by statute. In
response, Frausto offered the sworn affidavit of Karen
Wilkinson, an ARNP with more than 30 years of experience
"providing direct patient care, serving as clinical
nursing faculty for students providing care, and publishing
nursing texts on the subject." Clerk's Papers at
127, 136-37. Wilkinson stated her "professional
objective medical opinion, on a more probable than not basis,
" that the treating nurses breached the applicable
standard of care and that this breach proximately caused
Frausto's pressure ulcers. Id. at 128.
trial court held that while Wilkinson was certainly qualified
as an expert and could speak to the applicable standard of
care, the law did not permit Wilkinson to testify on the
issue of proximate cause. Frausto initially appealed to
Division Three of the Court of Appeals but later moved to
transfer the case to this court. Our commissioner granted the
motion. Ruling Granting Mot. to Transfer, Frausto v.
Yakima HMA, LLC, No. 93312-0 (Wash. Sept. 26, 2016).
ARNP express an opinion on proximate cause in a medical
malpractice case in accordance with RCW 7.70.040?
statutory scheme creates several categories of care providers
under the "nursing" umbrella-licensed practical
nurses, registered nurses, and ARNPs-each with varying
certification requirements and scopes of practice.
See RCW 18.79.040-, 060. Our legislature has
designated ARNPs as the highest tier of nurses,
"prepared and qualified to assume primary responsibility
and accountability for the care of patients" within the
narrow scope of their particular certifications. RCW
18.79.050; WAC 246-840-300(1). We need consider the
qualifications of only ARNPs for purposes of this case.
HMA asserts first that we should review the trial court's
ruling for abuse of discretion. Ordinarily, evidentiary
rulings are a matter of discretion by the trial court and
will not be upset on review absent an abuse of discretion,
McKee v. Am. Home Prods. Corp., 113 Wn.2d 701, 706,
782 P.2d 1045 (1989). However, it is not clear that the trial
court even attempted to exercise its discretion in resolving
an evidentiary issue, believing instead that our case law
foreclosed the possibility of Wilkinson's testimony on
proximate cause. Verbatim Tr. of Proceedings (Oct. 21, 2015)
(VTP) at 33 (noting that "the state of the law ... is
that the nurse, no matter how well qualified, isn't
capable of giving a decision on proximate cause"). In
any event, "[t]he de novo standard of review is used by
an appellate court when reviewing all trial court rulings
made in conjunction with a summary judgment motion."
Folsom v. Burger King, 135 Wn.2d 658, 663, 958 P.2d
301 (1998). Here, it is undisputed that the decision made by
the trial court that is on review was made pursuant to Yakima
HMA's motion for summary judgment. Because the trial
court dismissed this case on summary judgment, our review is
de novo. Aba Sheikh v. Choe, 156 Wn.2d 441, 447, 128
P.3d 574 (2006).
Washington, plaintiffs in a medical malpractice action must
prove two key elements: (1) that the defendant health care
provider failed to exercise the standard of care of a
reasonably prudent health care provider in that same
profession and (2) that such failure was a proximate cause of
the plaintiffs injuries. RCW 7.70.040. With regard to the
standard of care, we have repeatedly held that
'"expert testimony will generally be necessary to
establish the standard of care.'" Young v. Key
Pharm., Inc., 112 Wn.2d 216, 228, 770 P.2d 182 (1989)
(quoting Harris v. Groth, 99 Wn.2d 438, 449, 663
P.2d 113 (1983)). The expert must have "sufficient
expertise in the relevant specialty" such that the
expert is familiar with the procedure or medical problem at
issue. Id. at 229.
establish causation, the plaintiff must show that the alleged
breach of the standard of care "was a proximate cause of
the injury complained of." RCW 7.70.040(2). Like the
standard of care, expert testimony is always required except
in those few situations where understanding causation
"does not require technical medical
expertise." Young, 112 Wn.2d at 228 (giving
the examples of "amputating the wrong limb or poking a
patient in the eye while stitching a wound on the
face"). "Whether an expert is qualified to testify
is a determination within the discretion of the trial
court." Miller v. Peterson, 42 Wn.App. 822,
832, 714 P.2d 695 (1986). In this case, however, the trial
court did not believe it had any discretion to allow a
nursing expert to testify regarding medical causation as a
matter of law. VTP (Oct. 21, 2015) at 33.
we have not opined on this specific issue, the Court of
Appeals has offered conflicting analyses on this ...